Provider Demographics
NPI:1386907327
Name:MACLEAN, CJ
Entity type:Individual
Prefix:MS
First Name:CJ
Middle Name:
Last Name:MACLEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 BERGREN RD
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-9711
Mailing Address - Country:US
Mailing Address - Phone:850-934-5280
Mailing Address - Fax:
Practice Address - Street 1:2306 BERGREN RD
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-9711
Practice Address - Country:US
Practice Address - Phone:850-394-5280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL681286479OtherMEDICAID PROVIDER NUMBER